Healthcare Provider Details

I. General information

NPI: 1730759168
Provider Name (Legal Business Name): SUPREME HABILITATIVE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 11/27/2021
Certification Date: 11/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S ASHLEY DR STE 600
TAMPA FL
33602-5300
US

IV. Provider business mailing address

100 S ASHLEY DR STE 600
TAMPA FL
33602-5300
US

V. Phone/Fax

Practice location:
  • Phone: 813-381-0595
  • Fax:
Mailing address:
  • Phone: 866-751-8330
  • Fax: 813-922-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. RACKAYE J SIMMONS
Title or Position: CEO
Credential:
Phone: 866-751-8330